ModifiedBlue Cross Blue Shield - MainePolicy 04-202

Gingivectomy or Gingivoplasty (2021 Policy) PDF. Opens in a new window

Clinical guideline describing when gingivectomy or gingivoplasty is considered appropriate or contraindicated for treatment of periodontal disease, listing required documentation, limits, coding guidance, and laser use as adjunct without separate benefit. Applies to dental benefit determination and utilization review.

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyGingivectomy or Gingivoplasty (2021 Policy) PDF. Opens in a new window

Policy CodePolicy 04-202

Change TypeRevised

Effective DateJan 1, 2021

Next Review Date

Key ActionProvide current (within 12 months) dated 6-point periodontal charting and periodontal pocket probing chart performed after non-surgical therapy, and current pre-treatment radiographs with undistorted alveolar crest image.

SourceLink

POLICY UPDATE CHANGES

Policy status marked Revised with last review date 12/04/2020 and publish date 01/01/2021.

>=5mmPocket depth requirement

2Quadrants limit per date of service

1 per [36/60] moSurgical procedure frequency limit

Coverage Summary

scope_summary: Clinical guideline describing when Gingivectomy or Gingivoplasty is considered appropriate or contraindicated for treatment of periodontal disease, listing required documentation, limits, coding guidance, and that laser use is adjunctive and not separately payable.

coverage_stance: Mixed — procedures may be covered when criteria are met and are group contract dependent; not automatically payable solely because deemed necessary.

subject: Gingivectomy or Gingivoplasty.

Short summary: Gingivectomy/gingivoplasty is indicated for pocket elimination and gingival recontouring in supra-bony pockets after nonsurgical therapy has failed; laser adjuncts are considered part of treatment and are not eligible for a separate benefit, and dental necessity/coverage is determined per generally accepted dental standards (e.g., AAP, ADA) and the member's group contract benefits.

Key thresholds: pocket depth >= 5mm; required documentation within 12 months (current 6-point periodontal charting and post-nonsurgical probing); minimum healing interval after non-surgical therapy >= 6 weeks; frequency generally limited to 1 procedure per [36/60] months per tooth/quadrant (group dependent); maximum 2 quadrants per date of service (exceptions case-by-case).

Medically / Dentally Necessary Criteria

Medically/Dentally Necessary Criteria

Covered when ALL of the following are met:

ALL of the following

Periodontal charting: Current (within 12 months), dated 6-point periodontal charting indicating pocket depth recordings of a minimum of 5mm.within 12 months; >=5 mm
Reference AAP and ADA 6-point charting
Post-nonsurgical probing: A current (within the most recent 12 months) periodontal pocket probing chart, performed after completion of non-surgical periodontal therapy (e.g., 4341/4342) and/or periodontal maintenance (D4910), is required.within 12 months
Probing must be after non-surgical therapy
Radiographs: Current pre-treatment radiographs showing periapical area and undistorted image of the alveolar crest.within 12 months
Initial therapy and healing interval: Completion of initial periodontal therapy (e.g., scaling and root planing) with a minimum of six weeks allowed prior to any surgical treatment to permit tissue healing and assessment of non-surgical therapy success.>=6 weeks
Tooth type: Gingivectomy will be considered for treatment of periodontal defects involving natural teeth only.
Pocket depth requirement and frequency limit: Benefits are group contract dependent but generally limited to one periodontal surgical procedure in a [36/60] month period per single tooth or multiple teeth in the same quadrant and only if the pocket depth of the tooth is 5mm or greater.1 per [36/60] months; >=5 mm
Group contract dependent
Quadrant limit: Benefits will be limited to two quadrants per date of service; exceptions allowed on a case-by-case basis.<=2 quadrants per date of service
Exceptions case-by-case
Indication—supra-bony pockets: Gingivectomy or gingivoplasty is indicated for pocket elimination and gingival recontouring in the presence of supra-bony pockets with normal bony configuration when nonsurgical methods have been unsuccessful in removing subgingival deposits.supra-bony pockets
Used after unsuccessful nonsurgical therapy
Drug-induced hyperplasia: Gingivectomy or gingivoplasty may be used to remove loose or diseased gingival tissue and to re-sculpt excess gingival tissue from drug-induced gingival hyperplasia (e.g., phenytoin/Dilantin).

Contraindications / Not Appropriate

Not covered / contraindicated when ANY of the following apply:

ANY of the following

Infra-bony pockets: Treatment for infra-bony pockets.
Contraindication
Below mucogingival junction: Treatment of pockets extending below the mucogingival junction.
Contraindication
Minimal attached tissue: Presence of minimal amounts of attached keratinized tissue.
Contraindication
Access to alveolar bone: Procedures requiring access to alveolar bone.
Such procedures are contraindicated for gingivectomy/gingivoplasty

Procedure-Specific and Situational Rules

ALL of the following

D4212 restorative access: D4212 (gingivectomy to allow access for restorative procedures) may be considered when performed with crown(s)/restoration(s); benefits are group contract dependent and it is typically considered incidental to the primary restorative procedure.group dependent
Evaluate incidental status
Lasers/electrosurgery adjunct: The use of lasers or electrosurgery is considered adjunctive to treatment and is not eligible for an additional or separate benefit; do not bill laser use as a separate additional benefit.
Benefit determination treats laser as adjunct
Pericoronal tissue (D7971): Gingivectomy to remove inflamed/hypertrophied tissue around partially erupted or impacted teeth (excision of pericoronal tissue) should be coded as D7971.
Cosmetic after orthodontics: Codes D4210/D4211 are considered cosmetic when done within six months of orthodontic treatment; nonsurgical therapy (1110/4341/4342 and/or 4346) should be attempted first.within 6 months of orthodontics
Cosmetic determination
Coding guidance for bone removal: For non-restorative access that removes both gingival tissue and supporting bone, code as D4230 or D4231 (gingival flap procedure including root planing) rather than D4210/D4211/D4212.
When access requires removal of supporting bone use flap codes
D4212 diagnostics / incidental nested rule
- D4212 nested any: If diagnostics indicate periodontal support level appears to allow adequate access, the procedure may not be necessary.
- Consider incidental to placement of crown/restoration if information appears to not support the procedure.
- Evaluate per D4211: When submitted without associated restorative procedure evaluate per D4211 guidelines.
- Non-restorative access bone removal: For non-restorative access removing both gingival tissue and supporting bone code as D4230, D4231.

Coding

CDT procedure codes (informational list)mixed

D4210	Gingivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant.
D4211	Gingivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant.
D4212	Gingivectomy or gingivoplasty to allow access for restorative procedure, per tooth.
D4999	Unspecified periodontal procedure, by report
D4910	Periodontal maintenance (referenced in criteria)
D7971	Excision of pericoronal tissue (pericoronitis)
D4230	Gingival flap procedure including root planing - four or more contiguous teeth per quadrant (used for non-restorative access removing bone)
D4231	Gingival flap procedure including root planing - one to three contiguous teeth per quadrant (used for non-restorative access removing bone)

Provider Actions

Documentation Required

Submit current periodontal charting and probing

Provide a current (within 12 months) dated 6‑point periodontal charting and periodontal pocket probing chart performed after non‑surgical therapy, and current pre‑treatment radiographs showing the periapical area and an undistorted image of the alveolar crest. Charting is required to document pocket depths (minimum 5 mm threshold in criteria) and must be recent to support surgical necessity.

Affected codes: D4910, D4210, D4211, D4212
Charting within 12 months
Post-non-surgical probing (after 4341/4342 and/or D4910)
Pre-treatment radiographs with undistorted alveolar crest image

Documentation Required

Confirm prior non-surgical therapy and healing interval

Document completion of initial non‑surgical periodontal therapy (scaling and root planing) with the procedure codes and dates. Allow a minimum healing interval of six weeks after completion of 4341/4342 before performing any periodontal surgical procedure so tissues can be properly assessed for response to non‑surgical therapy.

Codes: 4341, 4342, D4910
Minimum healing interval: ≥ 6 weeks after scaling and root planing

Billing Rule

Limit quadrants and frequency

Benefits are generally limited to one periodontal surgical procedure in a [36/60] month period per single tooth or multiple teeth in the same quadrant, and benefits will be limited to two quadrants per date of service (exceptions case‑by‑case). These limits apply when determining coverage for gingivectomy/gingivoplasty.

Affected codes: D4210, D4211, D4212
Limit: 1 periodontal surgical procedure per [36/60] months per tooth or same quadrant
Limit: Maximum 2 quadrants per date of service

Billing Rule

Laser/electrosurgery adjunct billing

Use of lasers or electrosurgery is considered adjunctive to gingivectomy/gingivoplasty and is not eligible for an additional or separate benefit. Do not bill separately for laser or electrosurgery as an additional payable procedure.

Applies to all gingivectomy codes

Billing Rule

Cosmetic determination after orthodontics

Codes D4210 and D4211 are considered cosmetic when performed within six months of orthodontic treatment. Nonsurgical therapy and hygiene measures (e.g., D1110, 4341/4342 and/or 4346) should be attempted first before considering gingivectomy for cosmetic concerns related to recent orthodontic care.

Affected codes: D4210, D4211, 1110, 4341, 4342, 4346

Background

Gingivectomy and gingivoplasty are used to treat mild to moderate periodontal disease by eliminating pockets and recontouring gingiva in the presence of supra-bony pockets and normal bony configuration. These procedures are indicated when nonsurgical methods (scaling and root planing) have been unsuccessful in removing subgingival deposits and when removal of loose or diseased gingival tissue is needed to reduce pocket size.

Laser use is common for gingivectomy and various laser wavelengths may be used to incise gingiva for restorative, cosmetic, and periodontal needs; however, for benefit determination the use of lasers/electrosurgery is considered an adjunct to treatment and is not eligible for an additional or separate benefit.

Dental necessity and coverage determinations are made per generally accepted dental standards of practice and the member's group contract benefits. The policy references accepted standards and specialty guidance including the American Academy of Periodontology (AAP) and the American Dental Association (ADA) for charting, periodontal therapy guidelines, and CDT coding guidance.

Evidence

Standards referencedAAP and ADA 6-point charting; ADA CDT; AAP periodontal therapy guidelines

Policy Summary

PayerBlue Cross Blue Shield - Maine

PolicyGingivectomy or Gingivoplasty (2021 Policy) PDF. Opens in a new window

Policy CodePolicy 04-202

Change TypeRevised

Effective DateJan 1, 2021

Next Review Date

SourceLink

On This Page

OpenPayer

Gingivectomy or Gingivoplasty (2021 Policy) PDF. Opens in a new window

Coverage Summary

Medically / Dentally Necessary Criteria

Contraindications / Not Appropriate

Procedure-Specific and Situational Rules

Coding

Provider Actions

Background

Definitions

Revision History